CHRONIC SPECIFIC CHRONIC SPECIFIC BONE INFECTIONBONE INFECTION

DR.MARWAN ZAMZAMI,ABOSDR.MARWAN ZAMZAMI,ABOS

CHRONIC SPECIFIC CHRONIC SPECIFIC BONE INFECTIONBONE INFECTION

TUBERCULOSISTUBERCULOSIS BRUCELLOSISBRUCELLOSIS FUNGALFUNGAL SYPHILISSYPHILIS

TUBERCULOSISTUBERCULOSIS

THE BASIC MICROSCOPIC LESION; THE BASIC MICROSCOPIC LESION; THE THE TUBERCLETUBERCLE

FIRST DISCOVERED BY THE FRENCH FIRST DISCOVERED BY THE FRENCH PHYSICIAN PHYSICIAN LAENNECLAENNEC (1781-1826) (1781-1826) WHO DIED AT THE AGE OF 45 BY TBWHO DIED AT THE AGE OF 45 BY TB

TUBERCULOSISTUBERCULOSIS

ESTIMATED 30 MILLION TB PATIENTS ESTIMATED 30 MILLION TB PATIENTS WORLD WIDE.WORLD WIDE.

1 -3 % (300 000 – 1000 000) HAVE 1 -3 % (300 000 – 1000 000) HAVE SKELETAL INVOLVEMENTSKELETAL INVOLVEMENT

TUBERCULOSIS OF TUBERCULOSIS OF BONES AND JOINTSBONES AND JOINTS

TB Bacilli lived in symbiosis with TB Bacilli lived in symbiosis with mankind since time immemorial. mankind since time immemorial. Recorded in ancient Egyptian Recorded in ancient Egyptian mummiesmummies

Still common in developing countriesStill common in developing countries

REDUCED INCIDENCE REDUCED INCIDENCE OF TB DUE TO:OF TB DUE TO:

IMPROVED LIVING STANDARDS; IMPROVED LIVING STANDARDS; SANITATION, HYGIENE, SANITATION, HYGIENE, NUTRITIONNUTRITION

B.C.G. VACCINE (80% PROTECTION)B.C.G. VACCINE (80% PROTECTION)

TUBERCULOSIS BACILLITUBERCULOSIS BACILLI

MYCOBACTERIUM TUBERCULOSIS

BOVINEUNPASTEURISED MILK

HUMANMORE COMMON

OTHERSLESS COMMON

TUBERCULOSISTUBERCULOSIS

GROUPS AT RISK

NON AFFLUENT COUNTRIESOVER GROWING MALNUTRITION, POOR

AFFLUENT COUNTRIES IMMUNE DEFICIENT STEROIDS ANTICA

YOUNGER AGE OLDER AGE

TUBERCULOSISTUBERCULOSISFACTORS FAVORING FACTORS FAVORING

LOCALISATIONLOCALISATION

BLOOD SUPPLY AND STAGNATIONBLOOD SUPPLY AND STAGNATION LOCAL TRAUMA; HAEMATOMA?LOCAL TRAUMA; HAEMATOMA? LOCAL STEROIDS ?LOCAL STEROIDS ?

TB PATHOLOGYTB PATHOLOGY SecondarySecondary to other primary TB lesions (Pulm., GL, to other primary TB lesions (Pulm., GL,

Renal, LN)Renal, LN)

Route of spreadRoute of spread::HAEMATOGENOUS ****HAEMATOGENOUS ****DIRECT (much less)DIRECT (much less)

* bone to joint* bone to joint* soft tissue to bone* soft tissue to bone

THE PRIMARY LESIONTHE PRIMARY LESIONQUIESCENTQUIESCENTACTIVE: (Apparent, Latent)ACTIVE: (Apparent, Latent)

TB PATHOLOGYTB PATHOLOGY INFLAMMATION HYPEREMIA - OSTEOPENIAINFLAMMATION HYPEREMIA - OSTEOPENIA TB FOLLICLES (TUBERCLE):TB FOLLICLES (TUBERCLE):

LYPHOCYTE – MONOCYTESLYPHOCYTE – MONOCYTESENDOTHELIAL CELLSENDOTHELIAL CELLSLANGHANS GIANT CELLSLANGHANS GIANT CELLS

COALESCECOALESCE CASEATION LATERCASEATION LATER GRANULATION TISSUEGRANULATION TISSUE BONE DISTRUCTIONBONE DISTRUCTION SINUSESSINUSES

TB FollicleTB Follicle

TB PATHOLOGY (JOINTS)TB PATHOLOGY (JOINTS) SYNOVIAL SWELLINGSYNOVIAL SWELLING

GRANULATION TISSUEGRANULATION TISSUE PERIPHERAL ARTICULAR DESTRUCTIONPERIPHERAL ARTICULAR DESTRUCTION

NO PROTEOLYTIC ENZYMESNO PROTEOLYTIC ENZYMESCENTRAL ARTICULAR WEIGHT-CENTRAL ARTICULAR WEIGHT-

BEARING AREA PRESERVEDBEARING AREA PRESERVED RICE BODIESRICE BODIES

FIBRIN & ARTICULAR CARTILAGEFIBRIN & ARTICULAR CARTILAGE INCREASED BLOOD SUPPLYINCREASED BLOOD SUPPLY

OSTEOPENIAOSTEOPENIA

CLINICAL PICTURECLINICAL PICTURE

AGEAGE INSIDIOUS ONSETINSIDIOUS ONSET MONO ARTICULARMONO ARTICULAR OTHER LESIONSOTHER LESIONS FAMILY HISTORY – CONTACTFAMILY HISTORY – CONTACT GROUPS AT RISKGROUPS AT RISK

SYMPTOMS & SIGNS SYMPTOMS & SIGNS CONSTITUTIONALCONSTITUTIONAL

LOW GRADE FEVERLOW GRADE FEVER ANOREXIAANOREXIA WEIGHT LOSSWEIGHT LOSS NIGHT SWEATINGNIGHT SWEATING TACHYCARDIATACHYCARDIA ANEMIAANEMIA

SYMPTOMS & SIGNSSYMPTOMS & SIGNSLOCALLOCAL

Symptoms :Symptoms : PAINPAIN NIGHT CRIESNIGHT CRIES SWELLINGSWELLING STIFFNESSSTIFFNESS ULTERED ULTERED

FUNCTIONFUNCTION

Signs :Signs : WASTINGWASTING SYNOVIAL SWELLINGSYNOVIAL SWELLING TENDERNESSTENDERNESS WARMWARM STIFFNESSSTIFFNESS LIMPINGLIMPING

INVESTIGATIONSINVESTIGATIONS

LEUCOPENIA – LYMPHOCYTOSISLEUCOPENIA – LYMPHOCYTOSIS ANEMIAANEMIA RAISED ESRRAISED ESR MANTOUX POSITIVEMANTOUX POSITIVE

NOT IN: NOT IN:

MILIARY TB / RECENTLY VACCINATED/MILIARY TB / RECENTLY VACCINATED/

ON STEROIDS / REDUCED IMMUNITY / FEVERON STEROIDS / REDUCED IMMUNITY / FEVER

RADIOLOGYRADIOLOGY

CHEST X-RAYCHEST X-RAY : ALL PATIENTS : ALL PATIENTS JOINTSJOINTS: : PHEMISTER’S TRIADPHEMISTER’S TRIAD::

11. PERIARTIC. OSTEOPENIA. PERIARTIC. OSTEOPENIA22. REDUCED JOINT SPACE. REDUCED JOINT SPACE33. PERIPH. OSSEOUS EROSIONS. PERIPH. OSSEOUS EROSIONS

BONESBONES: : 1. DESTRUCTION1. DESTRUCTION2. SEQUESTRATION2. SEQUESTRATION3. ABSCESS FORMATION3. ABSCESS FORMATION

RADIOLOGYRADIOLOGY

BONE SCANBONE SCAN: MONO – ARTICULAR: MONO – ARTICULAR

CF: RHEUMATOID ARTHRITISCF: RHEUMATOID ARTHRITIS CALLIUM SCANCALLIUM SCAN INFECTION INFECTION CT SCANCT SCAN MORPHOLOGY MORPHOLOGY MRIMRI MORPHOLOGY MORPHOLOGY

DIAGNOSTICDIAGNOSTIC

ASPIRATION:ASPIRATION:AFB POSITIVEAFB POSITIVE

HISTOLOGICALHISTOLOGICAL CULTURECULTURE

TB SPINETB SPINESURGICAL PATHOLOGYSURGICAL PATHOLOGY

FIRST THREE DECADESFIRST THREE DECADES THORACO-LUMBARTHORACO-LUMBAR CENTRAL SPINECENTRAL SPINE

SPARKS POSTERIOR ELEMENTSSPARKS POSTERIOR ELEMENTSSPREADEDS UP/DOWN SPREADEDS UP/DOWN

ANT./POST. LONG. LIGS.ANT./POST. LONG. LIGS. LESIONS COALESCE – COLLAPSELESIONS COALESCE – COLLAPSE KYPHUS FORMATIONKYPHUS FORMATION

TB SPINETB SPINESURGICAL PATHOLOGYSURGICAL PATHOLOGY

PARA VERTEBRAL ABSCESSPARA VERTEBRAL ABSCESSCERVICALCERVICAL : RETROPHARALYGEAL: RETROPHARALYGEALTHORACICTHORACIC : P.V. & ALONG RIBS: P.V. & ALONG RIBSLUMBARLUMBAR : PSOAS ABSCESS: PSOAS ABSCESS

POSTERIOR:LUMBAR TRIANGLEPOSTERIOR:LUMBAR TRIANGLEANTERIOR: ILIAC FOSSAANTERIOR: ILIAC FOSSA

BELOW ING. LIG.BELOW ING. LIG. NEUROLOGICAL COMPLICATIONNEUROLOGICAL COMPLICATION

MORE IN THORACIC (NARROWEST CANAL) MORE IN THORACIC (NARROWEST CANAL)

TB SPINETB SPINECLINICAL FEATURESCLINICAL FEATURES

GENERAL: GENERAL: INSIDIOUS ONSETINSIDIOUS ONSET

CONSTITUTIONALCONSTITUTIONAL

LOCAL:LOCAL: PAIN – FIRST INDICATIONPAIN – FIRST INDICATION

LOCAL – REFERREDLOCAL – REFERRED

STIFFNESS – SPASMSTIFFNESS – SPASM

WEAKNESS – NEUROLOGICAL WEAKNESS – NEUROLOGICAL

SIGNS OF TB SPINESIGNS OF TB SPINE

MUSCLE SPASMMUSCLE SPASM KHPHUS – GIBBOUSKHPHUS – GIBBOUS TENDERNESSTENDERNESS STIFFNESSSTIFFNESS PARA VERTEBRAL ABSCESSPARA VERTEBRAL ABSCESS NEUROLOGICAL – WEAKNESS NEUROLOGICAL – WEAKNESS

PARAPLEGIAPARAPLEGIA

TB SPINETB SPINERADIOLOGICAL FEATURESRADIOLOGICAL FEATURES

DISC NOT INVOLVED PRIMARILYDISC NOT INVOLVED PRIMARILY NARROWING OF DISC SPACENARROWING OF DISC SPACE BONE DESTRUCTIONBONE DESTRUCTION

USUALLY TWO ADJACENT VERTEBRAEUSUALLY TWO ADJACENT VERTEBRAE MAY SHOW SKIP LESIONSMAY SHOW SKIP LESIONS PARA VERTEBRAL ABSCESSPARA VERTEBRAL ABSCESS KHYPUSKHYPUS CT/MYELOGRAM/MRI IN PARAPLEGIACT/MYELOGRAM/MRI IN PARAPLEGIA

PARAPLEGIA IN PARAPLEGIA IN TB SPINETB SPINE

IN 10-30% OF TB SPINEIN 10-30% OF TB SPINE MORE IN THORACIC REGIONMORE IN THORACIC REGION PRESSURE ON CORD ANTERO PRESSURE ON CORD ANTERO

LATERALLATERALMOTOR EARLIER THAN SENSORYMOTOR EARLIER THAN SENSORY

SIGNS: UPPER MOTOR NEURONSIGNS: UPPER MOTOR NEURONMAY START BY CORD SHOCKMAY START BY CORD SHOCK

REMARKABLE ABILITY TO RECOVERREMARKABLE ABILITY TO RECOVER

PARAPLEGIA IN TB SPINEPARAPLEGIA IN TB SPINECAUSED BY EXTRADURAL CAUSED BY EXTRADURAL

PRESSUREPRESSURE

GRANULATION TISSUEGRANULATION TISSUE PRESSURE OF ABSCESS & CASEATONPRESSURE OF ABSCESS & CASEATON SEQUESTRUMSEQUESTRUM PATHOLOGICAL FRACTURE/DISLOC.PATHOLOGICAL FRACTURE/DISLOC. SEVERE KYPHUSSEVERE KYPHUS INFLAMMATION: TOXIC EDEMA INFLAMMATION: TOXIC EDEMA

VASCULARVASCULAR

MANAGEMENT OF TB SPINEMANAGEMENT OF TB SPINE

USUALLY USUALLY CONSERVATIVECONSERVATIVE

GENERALGENERAL SPECIFICSPECIFIC

RESTREST

IMMOBILISEIMMOBILISE

CHEMOTHERAPYCHEMOTHERAPY

SURGICALSURGICAL DIAGNOSEDIAGNOSE

ASPIRATIONASPIRATION DRAIN ABSCESSDRAIN ABSCESS DEBRIDEDEBRIDE DECOMPRESSDECOMPRESS

ANTERIORANTERIOR

ANTERO-ANTERO-LATERALLATERAL

STABILISE FUSIONSTABILISE FUSION

MOST CASES OF TB SPINE RESPOND MOST CASES OF TB SPINE RESPOND VERY WELL TO CONSERVATIVE VERY WELL TO CONSERVATIVE

TREATMENT INCLUDING THOSE WITH TREATMENT INCLUDING THOSE WITH PARAPLEGIA PARAPLEGIA

THE NEED FOR SURGICAL THE NEED FOR SURGICAL DECOMPRESSION OF THE CORD IS DECOMPRESSION OF THE CORD IS

LIMITEDLIMITED

BRUCELLOSISBRUCELLOSIS

MILK AND MILK PRODUCTSMILK AND MILK PRODUCTS BACK PAIN AND STIFFNESSBACK PAIN AND STIFFNESS

MUSCLE SPASMMUSCLE SPASMFEVER – MILDFEVER – MILD

SACRO-ILIAC JOINTSACRO-ILIAC JOINT LESS DESTRUCTIVE OF TBLESS DESTRUCTIVE OF TB BRUCELLA TITREBRUCELLA TITRE ANTIBIOTICSANTIBIOTICS

e.g. SEPTRIN - OXYTETRACYCLINEe.g. SEPTRIN - OXYTETRACYCLINE

SYPHILISSYPHILIS

SPIROCHETESPIROCHETE

TREPONEMA PALLIDUMTREPONEMA PALLIDUM CONGENITAL SYPHILIS – COMMONESTCONGENITAL SYPHILIS – COMMONEST CHRONIC CHRONIC OSTEOCHONDRITISOSTEOCHONDRITIS

PERIOSTEITISPERIOSTEITIS

OSTEITISOSTEITIS TIBIA LESABRE TIBIATIBIA LESABRE TIBIA

FUNGAL INFECTIONFUNGAL INFECTION

CHRONIC – VERY LOW GRADECHRONIC – VERY LOW GRADE FEET – FARMERS – THORNS FEET – FARMERS – THORNS Madura FootMadura Foot SLOW DESTRUCTIONSLOW DESTRUCTION SINUSES – GRANULESSINUSES – GRANULES SECONDARY BACTERIAL INFECTIONSECONDARY BACTERIAL INFECTION RESISTANT TO CHEMOTHERAPYRESISTANT TO CHEMOTHERAPY NEEDS SURGICAL DEBRIDEMENTNEEDS SURGICAL DEBRIDEMENT IF ADVANCED MAY NEED AMPUTATIONIF ADVANCED MAY NEED AMPUTATION